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Form Approved. OMB No. 2050-0039 Please print or type GENERATOR ). 1 UNIFORM HAZARDOUS WASTE MANIFEST 1. Generator ID Number t. I..) I; I 6 8 %.; I.', 4 .4 2. Page 1 of 1 3. Emergency Response Phone 'it414,1114 ..1•1611 4. Manifest Tracking Number UZIU44i : JJK Generator's Name and Mailing Address Grin% $4 4 ) ..lif different fi r ! ,address) 1..)M ,:HI-.4t4OR STATI01,! 1.1 21 7.UrXERiii, ,1.1 P1.:, SAN rF'dkW,7,ISCO CA 94120 ':',TCTela(Vi 4 -' A 11 ,'l Generator's Phone: 8 0 CI 7 6 t - 6 6 0 0 I Transporter 1 Company Name U.S. EPA ID Number ' I ..! 011Inflt WONG , I.P I . , 887885 A. R Transporter 2 Company Name U.S. EPA ID Number I Designated Facility Name and Site Address U.S. EPA ID Number I IY"; Ili.. I I Mi :'...4 OF 1_.).)d I' 1."T :•9- )'' ' WV 81(Ift '1 Facility's Phone: ' 16 I NV -33881; :( 0 0 9an 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Urilt Waste Codas 13. HM and Packing Group (if any)) No. 'type Quantity WUVol. I1011 ROW% HAZARDOUS WASTE, SOLD }OILY S^I I rr i 36 • 1) Or ) ( '(, /C) i ---.....„.. Special Handling Instructions and Additional Information ,I(.11? I i 1 i •.11)1 ! ' ' : PP,"•li• 1 I . f.: f; 1.11 I' ' • .. i :7 i' -7 C.' , le / GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, ard are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable internalionaland national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) Is true. Generator's/Offeror's Printed/Typed Name 0 d., 1 i;. h e.,1 1 .1 d 4... ( (I.‘ (.... Signature Month Day Year I , , .. / . 1 •i I'I . i _, f- K International Shipments Import to U.S. Export from U.S. Pod of entry/exit: Transporter signalure (for exports only): Date leaving U.S.: TRANSPORTER Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name • Signature Month Day Year I , ( L.I )11'-'-'4 I . Transporter 2 Printed/Typed Name Signature Month Day Year I I I I DESIGNATED FACILITY Discrepancy 18a. Discrepancy Indication Space Quantity Type Residue Partial Rejection Full Rejection Manifest Reference Number: Mb, Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone: I 18c. Signature of Alternate Facility (or Generator) Month Day Year I I Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 1. 2. 3. 4. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a Printed/Typed Name Signature Month Day Year I I I I EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY